Alcohol is a natural substance formed by the reaction of
fermenting sugar with yeast spores.
Alcohol beverage known scientifically as ethyl alcohol and
chemically as C-2H-5OH and its abbreviation is EtOH.
Alcohol is classified as a food as it contain calories but has no
nutritional value. American beer contain 3-6% alcohol, wine-10 20% and distilled beverage contain 40 -50% alcohol.
Its create a pleasurable experience that encourage the drinker to
repeat it ; and abuse it.
The Diagnostic and Statistical Manual of Mental Disorder
(DSM-iv) seperates substance abuse disorder into to
categories. Substance –use disorder such as abuse and
dependence and substance- induced disorder such as
intoxication and withdrawal.
• Alcoholism dependence syndrome or
Alcoholism refers to the use of alcohol
beverages to the point of causing damage to
the individual, society or both.
III. EPIDEMIOLOGY OF ALCOHOL
• About half of American 12 years of age and older are
current drinker, of the these about ¼ are binge drinkers
or engage in heave alcohol use.
• The incidence of alcohol dependence is 2% in India.
While 20 -40% of subjected aged above 15 yrs are
Nearly 10 % of them are regular or excessive user.
Nearly , 15 -30 % of patient are developing alcohol –
related problems and seeking admission in psychiatric
III. ETIOLOGY OF ALCOHOL ABUSE
1. Biological factors :
Co-morbid psychiatric disorder / personality
Co-morbid medical disorders.
Re-enforcing effect of drugs.
Withdrawal effect and craving of drug use.
Biochemical factor (role of dopamine, nor
epinephrine in cocaine , ethanol and alcohol
General rebelliousness and social non-confirmity.
Early initiation of alcohol and tobacco.
Poor impulse control.
Sensation seeking .
Loss self esteem .
Concern regarding personal autonomy.
Poor stress management skill.
Childhood trauma or loss.
Relief from fatigue or boredom.
Escape from reality.
Lack of interest in conventional goals.
3 .SOCIAL FACTOR :
i. Peer pressure.
iii. Ease of availability of alcohol.
iv. Strictness of drug law enforcement.
v. Intra-familial conflict.
vi. Religious reasons.
vii. Poor social/ familial support.
viii.Perceived distance within the family.
ix. Permissive social attitude .
x. Rapid urbanisation
V. PROPERTIES OF ALCOHOL
Alcohol is a clear colored liquid with a strong burning
The rate of absorption of alcohol in the blood stream
is rapid than its elimination.
Absorption of alcohol into the blood stream is slower
with food in the stomach.
A small amount is excreted via urine and exhle.
Alcohol level of :
80 -100% in 100ml blood – Intoxication.
200 -250 mg- toxic, sleepy, confused and altered
300%/100ml -Loss of consciousness.
500%/100ml - Fatal.
VI. PHASES OF ALCOHOL ABUSE
Jellinek (1952) outlined phases of
Phase I The Pre- Alcoholic Phase:
The use of alcohol to relieve the
everyday stress and tension life.
Tolerance develops and the
amount required to achieve the
desired effect increase steadily.
Phase II The Early Alcoholic Phase
This phase begin with blackout –
brief period of amnesia that occur
during or immediately following a
period of drinking.
Alcohol is no longer a source of
pleasure or relief but rather a drug
that is required by individual.
Feeling of guilt and defensive about
drinking is seen.
Phase III The Crucial Period
The individual has loss control and
physiological dependence and
inability to choose whether or not to
In this phase individual is extremely
Drinking is the main focus and is
willing to risk everything that was once
Phase Iv The Chronic phase
It is characterized by emotional and
The individual is usually intoxicated more
often then sober.
Life threatening physical manifestation
may be evident.
Abstinent from alcohol result in various
VII. CLASSIFICATION OF ALCOHOLISn
Mostly in male
Age of onset
Genetic factor important &
May be positive
Parental alcoholism and
anti-social behavior usually
No loss f control.
and guilt present
Drinking followed by
Harm avoidance, high
VIII PATTERN OF ALCOHOL USE
A. ALPHA (A)
i. Excessive and inappropriate drinking to relieve
physical and or emotional pain.
ii. No loss of control.
iii. Ability to abstain alcohol present.
B. BETA (B)
i. Excessive and inappropriate drinking.
ii. Physical complication due to cultural drinking pattern
and poor nutrition.
iii. No dependence.
C. GAMMA (Y)
It I also called malignant alcoholism.
ii. Progressive course.
iii. Physical dependence with tolerance and withdrawal symptoms.
iv. Psychological dependence with inability to control drinking.
Inability to abstain.
iii. Withdrawal symptom.
iv. The amonut of alcohol consumed can be controlled.
Social disruption is minimal.
E. EPSILON (E)
Disomania ( compulsive drinking).
IX SIGN AND SYMPTOM OF
Minor complaint: malaise, dyspepsia, mood swing or
depression, increased incidence of infection.
Poor personal hygiene, untreated injuries.
Unusual high tolerance for sedative and opiod.
Consumption of alcohol containing product.
Denial of problems.
Tendency of blaming others and rationalize problems.
ICD 10 CRITERIA FOR ALCOHOL
A strong desire to take the substance.
Difficulty in controlling substance taking
A physiological withdrawal state.
Development of tolerance.
Progressive neglect of alternative pleasure of
Persisting with substance use despite clear
evidence of harmful consequences.
X. TYPES OF INTOXICATION OF
1. ACUTE INTOXICATION
After a brief period of excitation, there is generalized
central nervous system depression with alcohol use.
With increasing intoxication, there is increases reaction
time, slow thinking, distractibility and poor motor
control, later dysarthria, ataxia and in coordination can
occur with progressive loss of self control and frank
Intoxication sign are seen in blood alcohol level of 150
–200mg%, at 300 -450gm% increasing drowsiness
followed by coma. Blood alcohol level of 400 –
800gm% is fatal.
A small dose of alcohol causing intoxication is known
as ‘pathological intoxication’.
2. WITHDRAWL SYNDROME
The withdrawal symptom most commonly seen is a hang over on
the next morning. Mild nausea, vomiting, weakness, irritability,
insomnia and anxiety are common withdrawal symptom. Some
severe symptoms are –
a. Delirium tremors (DT) :
It is most severe withdrawal symptom and death occur in 5 – 10%.
It occurs usually in 2- 4 days of complete abstinence of alcohol.
The course is short with recovery within 3-7 days.
This is organic brain syndrome, characteristic feature are- Clouding of consciousness.
-Poor attention span and distractibility.
-Visual and auditory hallucination.
-Marked autonomic disturbance.
-Psychomotor agitation and ataxia.
- Dehydration and electrolyte imbalance.
b. Alcoholic Seizures (Rum Fit )
• It is generalized tonic clonic seizure occur in 10%
alcohol dependence, usually after 12- 24 hours
after heavy bout of drinking.
• Multiple seizure ( 2- 6 at one time) are common.
• Status epilepticus may be precipitated and 30 %
cases , delirium tremors follows.
c. Alcoholic Hallucinosis
• It is characterized by presence of halucintion
during partial or complete abstinence following
regular alcohol intake.
• Usually recover after 1 month or rarely more than
d. Wernicke’s encephalopathy
• This is an acute reaction due to severe deficiencies of thiamine.
• Characteristically the onset occurs after period of persistent
vomiting. Its important clinical sign are-Ocular sign: coarse nystagnes, opthalmoplegia, pupillary
irregularities, retinal hemorrhage, papillo edema, etc.
-Higher mental function disturbances.
-Peripheral neuropathy and severe malnutrition.
e. Korsakoff’s psychosis
• It is identified by syndrome of confusion, loss of recent memory
• It is frequently encountered in client recovering from Wernicke’s
• In USA, these two disorder are called together as “Wernicke’sKorsakoff.
XI. LABORATORY INVESTIGATION
1. GGT ( Gamma Glutryl
2. MCV ( Mean
4. Echo, ECG and X-ray.
5. MAST (Michigan
6. Body Fluid Alcohol
XII. CAGE QUESTIONAIRE
• CAGE questionnaire is an acronym of its four question, widely used for
screening for alcoholism.
• It was developed by John Ewing, founding director Boules Center for
alcohol Studies, University of North Caroline.
• CAGE questionnaire are –
1.Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking.
3.Have you ever felt Guilty about drinking.
4. Have you ever needed Eye opener drink( early in he morning)?
Give 1 for each “yes” answer.
A score of 2 or more identifies problems drinkers.
Question 1 “yes” – 25% alcoholic.
Question 2 “yes” -50% alcohol problems.
Question 3 “yes” – 75% alcohol problems.
Question 4 “yes” – 95% alcohol problems.
XIII. MANAGEMENT OF ALCOHOL
It is the treatment for alcohol withdrawal and drug of choice is
The most commonly used drug are chlordiazepoxide 80 -200mg
and diazepam 40 -80 mg/day in a divided dose.
- Fluid and electrolyte balances.
C. Alcohol deterrents therapy
These agent are those which are given to desensitize the individual to
the effect of alcohol and maintain abstinence in treatment of alcohol
dependence. It main effect is to produce rapid and violently
unpleasant reaction in a person who ingest even a small amount of
alcohol while taking disulfiram
Disulfiram: It is used to ensure abstinence in treatment of alcohol
dependence. It main effect is to produce rapid and violently
unpleasant reaction in a person who ingest even a small amount of
alcohol while taking disulfiram.
Mechanism of action :
It is an aldehyde dehydrogenase inhibitor that interferes with
metabolism of alcohol and produce a marked increases in blood
acetaldehyde level( more than 10 time level) producing wide array
of unpleasant reaction called ‘ Disulfiram ethanol reaction’.
DER is characterized by nausea, throbbing headache, vomiting,
hypotension, flushing, sweating, thirst. dyspnea, tachycardia chest
pain, vertigo, blurred vision with severe anxiety.
Therapeutic indication: Aversive conditioning treatment for alcohol
Side effect : Fatigue, dermatitis, impotence, optic neuritis, mental
change, acute polyneuropathy and hepatic damage. In extreme
casa convulsion, respiratory depression, cardio vascular collapse,
myocardial infarction and death.
• Contraindication :
-Pulmonary and cardio vascular diseases.
-Use cautious in renal, CNS ,hormonal disorder.
-Patient at risk of alcohol ingestion.
• Dosage: Initial dose is 500mg/day orally for first 2week and
followed by 250mg/day.
• Nursing responsibilities:
12 hour should lapse since last ingestion of alcohol before
administering the drug.
Instruct and warn patient not to take alcohol and alcohol
Caution patient against taking CNS depressant or OTC.
Instruct patient to avoid driving.
Warned that DER can last till 2 week after the therapy.
Instruct to carry identification card.
Emphasize importance of follow up.
XIV. TREATMENT OF ALCOHOL ABUSE
• The best way to stop alcohol is to stop it suddenly.
• The aim of detoxification is symptomatic
management of emergent with drawal symptom.
• The drug of choice area. Chlordiazepoxide
-20mg QID in day 1.
-15mg QID in day 2.
-10 mg QID in day 3.
-5mg QID in day4.
-5mg BD in day 5 and none in day 6.
-40 -80 mg/day in divided dose.
- 1-3g/day (for experimenrtal used).
- 600 – 1600 mg/day (for experimental used
Vitamin b ( 10mg thiamine ) twice every day for 3
-5 days , followed by oral route at least 6 month
Care of dehydration ,without giving DW 5%.
2. Behavior therapy.
• Aversion therapy using a sub- threshold electric
• Convert sensitization, relaxation technique,
assertiveness technique, assertive training, self
control skill and positive reinforcement.
• It can be both group and individual group therapy.
• Education about alcohol and its risk is given.
• Motivational enhancement therapy and lifestyle
modification is useful.
4. Group therapy:
• Alcohol Anonymous.
5. Deterrent agent (Alcohol sensitizing drug):
i. Citrated Calcium Carbonate.
iii. Animal charcoal, cephalosporin,etc.
-Acamprosate ( the ca++ salt of N-acetylhomotaurinate)
-Naltrexone (oral opiod receptor antagonist)
- Anti-depressant, anti- psychotic, narcotis,
XV. NURSING MANAGEMENT USING
1. Risk for injury related to hallucinosis, acute
intoxication secondary to confusion,
disorientation, inability to identify potentially
2. Altered health maintenance related to inability
to identify, manage or seek out help to
maintain health, evidenced by various physical
symptom, exhaustion, sleep disturbance.
3. Ineffective denial related to weak, underdeveloped ego, evidence by lack of insight,
blaming others, failure to accept responsibilty
for his behavior.
4. Ineffective individual coping related to
impairment of adaptive behavior and
problem solving abilities evidenced by use of
substance as coping mechanism.
5. Disturb family process related to alcoholism
as evidenced by relationship discord,
frequent flight, misunderstanding and
XVI.AGENCIES CONCERNED WITH
ALCOHOL RELATED PROBLEM:
This is a self-help organization
founded in the USA by tow
alcoholic men, Dr. Bob Smith
and Bill Wilson, a stokbroker
on the on the 10th of June in
The organization works on the
firm belief that abstinence
must be complete. The only
requirement for membership
is a desire to stop drinking.
Started in late 1950 by
Mrs Anne, wife of Dr.Bob
to support the spouse of
The parent, children,
spouse, partner, siblings,
family member, friends,
employer, employees and
co-workers of alcoholic
are the members.
AL-teen is a part of AL-Anon family.
It is a family group which provides
support to their teenage children
These are intended mainly
for those rendered homeless
due to alcohol related
XVII: COMPLICATION OF CHRONIC
A. Medical complication:
a. Central nervous systemi. Peripheral Neuropathy
ii. Delirium tremors
iii. Run fits
iv. Alcohol hallucinosis
v. Alcoholic jealousy
vi. Wernicke Korsakoff psychosis
vii. Manchiajava-Bignani disease
viii. Alcoholic dementia
x. Cerebrellar degeneration
xi. Central pontire myeliniosis
xii,. Head injury and fracture.
B. Gastro- Intestinal Complication
-fatty liver, cirrhosis of liver, hepatitis
-gastritis, reflux oesphagitis, peptic ulcer, ca.
stomach and esophagus.
Malabsorption syndrome, protein-losing
enteropathy, portal hypertension, ascitis.
- pancreatitis, pancreatic cancer.
Acne mosacea, palmar
erythema, rhinophyma, spider
naevi, parotid enlargement.
Foetal alcoholic syndrome
Alcoholic hypoglycaemia and
d. Cardiovascular complication
e. Genito –urinary(GU) system
B. SOCIAL COMPLICATION:
Increase incidence of drug
• Financial difficulties.
Every 10 people , who say they will stop drinking,
only 4 do.
Over 700,000 people per day receive treatment for
Approximately 20% achieve long term soberity
Approximately 50 – 60 % remain abstinent at the
end of a end of year after treatment.
Motivation and intervention by family or friend can
help the alcoholic achieve abstinence.
Those with poor, social support, poor motivation or
psychiatric disorder has poor prognosis and tend to
relapse within a few years of treatment.
Alcohol is the major ingredient in many over
the counter and prescription medicine that are
prepared in the concentrated form.
Alcohol can be harmless and enjoyable- sometimes
if it is used responsibly and in moderation.
Alcohol has the potentiality for abuse.
For alcoholic dependence management the
degree of individual involvement and family
support is equivalent.
The goal for treatment of alcohol dependence is
abstinence, which need a lot of motivation from
patient and family.